Mumtaz (name changed), 57, works in a brothel in Sonagachi, Kolkata. She has been here 30 years. This redlight area in the northern part of the city is perhaps South Asia's largest. With a sunken face and a strong jawline, Mumtaz has an intense look in her eyes. Too old to practice sex work any more, Mumtaz is now become a 'madam' with four girls living in her rented accommodation. She is also a supervisor to four peer educators - women from the community who persuade their peers to be more health conscious. They promote the use of condoms, raise awareness about HIV, and encourage women to seek treatment for sexually transmitted infections (STIs).

Community work comes easy to Mumtaz. In the early 90s, she was one of the 12 women who came together to fight for the rights of sex workers and laid the foundation for Durbar Mahila Samanwaya Committee, now a collective of more than 65,000 women in sex work across West Bengal. A formidable body, the DMSC has addressed sex workers' issues such as violence from partners, clients and police. It also addresses issues such as livelihood, savings, and the education of children. Its self regulatory board prevents the entry of minors into the sex trade and ensures women who work here do so consensually.

Sexual health awareness is high, and service uptake at DMSC's clinics offering STI treatment to women and their clients has been steadily increasing. Dr Protim Ray, who has been with DMSC's STI clinics since their inception, says consistent condom use in Sonagachi is about 86 per cent. That's a substantial number. As a collective women are better able to negotiate its use. Mumtaz recounts earlier days when women would be forced into sex without a condom by the client or even the madam. Not anymore. "As a madam, I make it mandatory that all encounters in my 'house' are with condom," she says firmly.

Clearly, the condom awareness message has gone down strong in brothels. Tapashi, 27, who manages a Community-Based Organisation in the Dinbazaar redlight area of New Jalpaiguri, North Bengal, says, "We are constantly telling women to use the condom. Only if all women decide together can we ensure no sex without condom."

The female condom

Given that the condom is the most effective means to prevent STI and HIV, its normalisation is heartening. Yet, gaps remain. There is the regular
partner or 'husband' whom the women call babu. It's not possible to bring up the subject of condom use with him, they say. There is also the drunken client and
difficult client who simply refuses to use the condom. There are instances of very 'powerful' clients with whom women cannot insist on the condom. Public health
experts are now exploring ways and means to cover these gaps. There's some new hope on this front: The Hindustan Latex Family Planning Promotion Trust and National
AIDS Control Organisation has introduced the female condom among women at risk in six states under a pilot project that began this April. The female
condom aims to cover gaps where the male condom is not being used.

Through select NGOs working on HIV prevention among sex workers, the female condom has been introduced in six states. These include the high HIV-prevalence states Andhra Pradesh, Tamilnadu, Karnataka, and Maharashtra, and low-prevalence states Gujarat and West Bengal. Imported from the Female Health Company, UK, at a cost of Rs.45, it is being socially marketed at five rupees.

Women say the female condom takes about three to four times of use to learn how to insert it properly and get accustomed to it.

In West Bengal, DMSC has introduced it in some areas of Sonagachi and Boubazaar in Kolkata, and the Khalpara redlight area of Siliguri. In New Jalpaiguri, CBO Jalpaiguri Hriday has introduced it among brothel workers as well as 'hidden' sex workers - women who live in homes and families and also sell sex. In Kolkata, NGOs Chitranjan Welfare and Research Centre and Calcutta Samaritans are also reaching out to 'hidden' sex workers with this new product. Six months from the launch of the effort, the response has been encouraging. Women say they don't have to turn away a client who doesn't want to use the male condom. Clients don't mind women using something as long as they don't have to use one. Women control its use, there is no chance of it tearing, or incorrect use, and that makes them feel confident and safe. Response from clients has been good and they are evening willing to pay more.

The pilot aims to track use of the female condom among women at risk in a small group of consistent users. Says Hyderabad-based Kavitha Potturi, of HLFPPT: "We want to track women who are using the product over a few months so that we can understand all aspects of its use - user feedback, client response, impact on sexual behaviour, social marketing."

In West Bengal, NGOs have kept their group of consistent users limited to just about 200 women per NGO. Interpersonal communication is playing a critical role. All NGOs are following the peer-led approach to promote the female condom not as a replacement to the male condom, but as an added choice. Women say it takes about three to four times of use to learn how to insert it properly and get accustomed to it.

Smita, 24, an outreach worker at Kolkata's CWRC says, "With a product like this, we know any message will spread like wildfire among the community - whether it is positive or negative. It is important that users' issues and problems are addressed." In Khalpara, Siliguri's redlight area, a 45-year-old former sex worker says its large and unwieldy size makes the female condom a very intimidating product. Further, demonstrating its use is difficult. "Unlike the male condom, which in the earlier years, we used to demonstrate using a cucumber or a brinjal or even a finger, it is difficult to demonstrate the use of a female condom. One peer educator even inserted it for a woman for the first time. But it is an extremely good product and once women get the hang of it, they will be in total control," she says.

At risk from regular partners too

With the client gap more or less covered, public health experts warn that the regular partner ('husband') still remains a worrying gap, and this is where sex workers are getting infected. Some women see themselves at risk from their regular partner, some don't. Tapashi, herself the daughter of a sex worker, says of the 180 women in Dinbazaar, New Jalpaiguri, about 30-40 have babus or 'husbands'. "Our peer educators reach out to the babus. When we tell them to use the condom they snap back at us - 'do you use the condom with your husband?' Yes, I tell them. 'Then where did the children come from,' they say sarcastically. I tell them I had children when I wanted to. It is very tough to talk to them about condom use, let alone convince them of its need," she says.

Peer educators are focusing on promoting the female condom with the babu where it seems impossible to suggest use of male condom. At Sonagachi, DMSC has also set up a babu sanghathan. "Yet, there's only so much we can do. We cannot monitor if the condom is actually being used in these relationships," says counselor Paulomi Bhowmick at the Avinash STI clinic in Sonagachi.

Women who use the female condom with their regular partner or husband say male response has been good. Else, they would not have been able to use it. One woman said insisting on the male condom was resulting in domestic violence. "Even the children were getting affected. Now I just use the female condom. The stress has reduced." Another woman said insisting on the male condom was a barrier in building relationships of trust and bonding. "I know I am at risk, men don't want to use the condom, I had to turn them away. Now, I just use the female condom." Men don't seem to mind, in fact, they seem to like it. "One client took some female condoms from me for his wife," said a woman.

High awareness about the risk of HIV, and the fight for collective rights have improved health and living conditions for women living in brothels.
Older women look back at the journey they have traveled and are proud of the community work done over the last 15 years. There has been a sea change, they say. Women
are willing to try anything that might keep them safe, protect them from HIV and STI. If doing so results in additional income, and helps build
relationships, so much the better.

Sumita Thapar09 October 2007

Sumita Thapar is a freelance journalist and a consultant with CFAR. She has been working and writing on HIV/AIDS.

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